Brigham Clinicians Help Develop COVID-19 Clinical Guidance

“Who knew that rheumatology patients would be right in the middle of the COVID-19 crisis?”

This question was posed by rheumatologist Karen H. Costenbader, MD, MPH, director of the Brigham and Women’s Hospital Lupus Program and chair of the Medical and Scientific Advisory Council for the Lupus Foundation of America. In these roles, she has found herself at the center of the controversy around the use of hydroxychloroquine (HCQ) and other rheumatology medications in COVID-19.

HCQ is the cornerstone therapy for systemic lupus erythematosus (SLE). It’s also used for other rheumatic diseases, including cutaneous lupus, rheumatoid arthritis and Sjogren’s syndrome. The COVID-19 outbreak, and resulting HCQ shortages, have created new challenges for rheumatologists and their patients.

The American College of Rheumatology (ACR) released clinical guidance to assist rheumatology providers in managing adult rheumatic disease patients during this pandemic. Ellen M. Gravallese, MD, immediate past ACR president and chief of the Brigham’s Division of Rheumatology, Inflammation and Immunity, convened and serves on the task force that prepared the guidance document. Given her expertise in lupus, Dr. Costenbader serves on the task force as well.

Two other Brigham clinicians are also on the ACR COVID-19 Clinical Guidance Task Force, which is comprised of 10 rheumatologists and four infectious disease specialists:

“The ACR and the Lupus Foundation have been very vocal advocates for rheumatology patients and physicians, and it’s important that we remain so as the situation continues to evolve,” Dr. Costenbader said.

Building Consensus on Recommendations for Rheumatic Care

Task force members began their work by submitting clinical questions that rheumatologists are most likely to have in the face of COVID-19. The panel then broke up into three teams to discuss the questions, research evidence and craft recommendations. The entire task force came together several times to review and revise the questions and statements.

Using a modified Delphi process for consensus building, the task force swiftly completed a draft summary, which the ACR Board of Directors approved on April 11. “It was an interesting process—very well run,” Dr. Costenbader said. “The goals were both to gather the highest-quality evidence and to get this out quickly because so many people need this information.”

The clinical guidance covers the following scenarios involving rheumatic patients in the setting of COVID-19:

  • Ongoing treatment of stable SLE, rheumatoid arthritis and other rheumatic disease patients in the absence of infection or SARS-CoV-2 exposure
  • Treatment of newly diagnosed or active rheumatic diseases in the absence of infection or SARS-CoV-2 exposure
  • Ongoing treatment of stable patients following SARS-CoV-2 exposure (without symptoms related to COVID-19)
  • Rheumatic disease treatment in the context of documented or presumptive COVID-19 infection

Noting the plethora of ongoing trials for COVID-19, including some involving rheumatology medications, Dr. Costenbader stressed that the task force will update the clinical guidance as new evidence becomes available.

“This will be a living document,” she said. “There will be more results available as more studies come out, and that will influence what we recommend about the use of hydroxychloroquine and other medications.”